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WHEN THIS '" COPY CARRIES THE RAISED SEAL OF THE , STATE OF NEBRASKA, IT CERTIFIES THE DOCUMENT BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE 3/21/2019 LINCOLN, NEBRASKA 201902121 RUSSELL FOSLER ASSISTANT STATE REGISTRAR DEPARTMENT OF HEALTH AND HUMAN SERVICES STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HUMAN SERVICES CERTIFICATE OF DEATH Pursuant to section 30-2413, demands for notice which may affect the estate of the deceased are filed with the t ounty court in the county where the decedent resided at the time of death. 1. DECEDENTS -NAME (First, Middle, Last, Suffix) Kenneth Lee Partridge ` 2. SEX Male 3. DATE OF DEATH (Mo., Day, Yr.) March 11, 2019 4. CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE - Last Birthday 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6. DATE OF BIRTH (Mo., Day, Yr.) Burwell, Nebraska (Yrs.) 69 MOS. DAYS HOURS MINS. February 28 1950 7. SOCIAL SECURITY NUMBER 505-68-4026 8a. PLACE OF DEATH HOSPITAL 0 Inpatient OTHER E Nursing Home/LTC ❑ Hospice Facility _. Sb. FACILITY -NAME (If not Institution, give street and number) Wedgewood Care Center 0 ER/Outpatient 0 Decedent's Home 0 DOA 0 Other (Specify) 8c. CITY OR TOWN OF DEATH (Include Zip Code) Grand Island 68803 8d. COUNTY OF DEATH Hall 9a. RESIDENCE -STATE Nebraska 9b. COUNTY Hall 9c. CITY OR TOWN Grand Island 9d. STREET AND NUMBER 905 S. Sycamore St. 9e. APT. NO. 9f. ZIP CODE 68801 9g. INSIDE CITY LIMITS 1E1 YES 0 NO 10a. MARITAL STATUS AT TIME OF DEATH E Married 0 Never Married ❑.Married, but separated 0 Widowed 0 Divorced 0 Unknown 10b. NAME OF SPOUSE (First, Middle, Last, Suffix) If wife, give maiden name Annette Walsh 11. FATHER'S -NAME (First, Middle, Last, Suffix) Marvin Partridge 12. MOTHER'S -NAME (First, Middle, Maiden Surname) Berniece Johnson 13. EVER IN U.S. ARMED FORCES? Give dates of service if Yes. (Yes, No, or unk.) No 14a. INFORMANT -NAME Annette Partridge 14b. RELATIONSHIP TO DECEDENT Wife 15. METHOD OF DISPOSITION ❑ Burial EI Donation 16a. EMBALMER -SIGNATURE Not Embalmed 16b. LICENSE NO. 16c. DATE (Mo., Day, Yr.) March 15, 2019 ® Cremation D Entombment 0 Removal 7❑ Other (Specify) 16d. CEMETERY, CREMATORY OR OTHER LOCATION CITY / TOWN STATE Central Nebraska Cremation Services Gibbon Nebraska 17a. FUNERAL HOME NAME AND MA LING ADDRESS (Street, City or Town, State) All Faiths Funeral Home. 2929 S. Locust Street, Grand Island. Nebraska 17b, Zip Code 68801 CAUSE OF DEATH (See instructions and examples) 18. PART I. Enter the chain of events- -diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary. IMMEDIATE CAUSE: IMMEDIATE CAUSE (Final a) Respiratory Failure disease or condition resulting onset to death 12 Hours al death) DUE TO, OR AS A CONSEQUENCE OF: sequentially list conditions, it :' b)Metastatic Squamous Cell Carcinoma Of The Head And Neck any, leading to the cause listed on line a. onset to death 6 Weeks DUE TO, OR AS A CONSEQUENCE OF: Enter the UNDERLYING CAUSE c) Intracranial Edema With Intracranial Shift (disease or injury that initiated onset to death 3 Weeks the events resulting In death) DUE TO, OR AS A CONSEQUENCE OF: LAST d) Dysphagia onset t0 death 6 Weeks 18. PART II. OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death but not resulting in the underlying cause given in PART I. Diabetes Mellitus Type 2, Coronary Artery Disease, Becker Muscular Dystrophy, Obesity 19. WAS MEDICAL EXAMINER OR CORONER CONTACTED? ❑ YES E NO 20. IF FEMALE: ❑ Not pregnant within past year ❑Pregnant at time of death 21a. MANNER OF DEATH E Natural ❑ Homicide 0 Accident ❑ Pending Investigation 21b. IF TRANSPORTATION INJURY 0 Driver/Operator ❑ Passenger 21c. WAS AN AUTOPSY PERFORMED? ❑ YES E NO fl u,, ,c7,1.,...t, c -;^'-. •^ lays „A ::,...•;, 0 Not pregnant, but pregnant 43 days to 1 year before death 0 Unknown if pregnant within the past year ❑ Suicide 0 Could not be determined ❑ Pedestrian ❑ Other (Specify) 21d. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? ❑ YES ❑ NO 22a. DATE OF INJURY (Mo., Day, Yr.) 22b. TIME OF INJURY 22c. PLACE OF INJURY -At home, farm, street, factory, office building, construction site, etc. (Specify) 22d. INJURY AT WORK? YES ONO 22e. DESCRIBE HOW INJURY OCCURRED 22f. LOCATION OF INJURY - STREET & NUMBER, APT.NO. CITY/TOWN STATE ZIP CODE robe completed by MEDICAL CERTIFIER ONLY 23a. DATE OF DEATH (Mo., Day, Yr.) March 11 2019 To be completed by CORONER'S PHYSICIAN or COUNTY ATTORNEY ONLY 24a. DATE SIGNED (Mo., Day, Yr.) 24b. TIME OF DEATH 23b. DATE SIGNED (Mo., Day, Yr.) March 12, 2019 23c. TIME OF DEATH 11:00 PM 24c. PRONOUNCED DEAD (Mo., Day, Yr.) 24d. TIME PRONOUNCED DEAD 23d. To the best of my knowledge, death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) Mathew Day, MD 24e. On the basis of examination and/or investigation, in my opinion death occurred at the time, date and place and due to the cause(s) stated. (Signature and Title) 25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? ❑ YES E NO 0 PROBABLY ❑ UNKNOWN 26a. HAS ORGAN OR SSUE DO ATION BEEN CONSIDERED? ❑ YES ONO 26b. WAS CONSENT GRANTED? Not Applicable if 26a is NO 0 YES El NO 27. NAME, TITLE AND ADDRESS OF CERTIFIER (Type or Print Mathew Day, MD, 729 N Custer Ave, Grand Island, Nebraska, 68803 28a. REGISTRAR'S SIGNATURE _,_- 28b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)spdteP March 18, 2019 t �{-